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General NPI Number Information
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NPI Number | 1548687072
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Entity Type | Organization
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Legal Business Name | IDEAL FAMILY DENTISTRY
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Dates
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Enumeration Date | 03/21/2014
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Last Update Date | 04/29/2014
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Provider Practice Location Address
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Address Line | 700 W IRONWOOD DR STE 241
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2656
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Country | US
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Telephone | 208-664-4831
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Fax | 208-666-1804
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Provider Business Mailing Address
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Address Line | 700 W IRONWOOD DR STE 241
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2656
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Country | US
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Telephone | 208-664-4831
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Fax | 208-666-1804
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Authorized Official
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Title or Position | DENTIST
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Name | JOHN COBURN
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Credential | DMD
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Telephone | 208-664-4831
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D-4188
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License Number State | ID
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